August 2008

Ever have a patient flirt?

by Timothy J. Feuling

The problem is so common, there's even a name for it: transference. It's when a patient confuses gratitude or compassion for love. Some imagine they are falling in love with the doctor. Others, given the physical nature of the encounter, mistake physical contact for sexual overtures. Finally, there are those patients who almost automatically go into "flirt mode" whenever they are in the company of the opposite sex.

As Valerie Gibson, advice columnist for Sun Media explains, "It's not unusual ... for some women to fall in love with their doctor. Maybe he's the only man who listens to them, shows an interest in their problems and tries to help them. Or maybe when a woman's lonely she tends to project her fantasies."

Despite Gibson's reference to women falling in love with their male doctors, the reverse also happens -- a male patient can interpret his gratitude toward his female chiropractor as something less professional. Or, he may merely be trying to assert his masculinity by falling into the old "sex games" mode.

Transference has always been linked primarily with psychologists and other mental health care providers, but chiropractors increasingly have to deal with the issue as well.

"Physicians often do not realize the enduring nature of the doctor-patient relationship and do not appreciate that the transference phenomenon is not limited to psychiatric care. Even a brief association with the physician can significantly affect the patient," stated Cheryl Winchell, MD in the American Family Physician.

In some cases, a patient may make verbal advances by suggesting that she enjoys the touch of the doctor's hands on her back, hinting she'd love to meet socially or that she finds the doctor's "bedside manner" appealing.

Some such statements may be perfectly innocent, but also may be the patient's way of feeling out the doctor's willingness to reciprocate. Other advances are less subtle.

In one doctor's office, a patient repeatedly removed her blouse during the examination, even though she was told that disrobing was unnecessary. In another, a male patient made jokes about his evident arousal on the adjusting table.

While most of these situations resolve themselves without any difficulty, enough escalate into major problems to make them a risk management issue. Doctors who fail to rebuff their amorous or flirtatious patients may later be accused of leading them on, while those who do rebuff them can end up being the target of their hostility. It's a no-win situation that requires immediate and careful action to avoid.

As always, prevention is the best "medicine" when it comes to risk management.

The safest procedure is to always make sure your CA is in the room with you when adjusting or examining a patient of the opposite sex.  (Note: Gay and lesbian doctors should be equally careful with patients of the same sex if their sexual orientation is well known to their patients.) When possible, the CA should be the same sex as the patient.

Obviously, this isn't always feasible. A compromise would be to keep the door of the adjusting/examination room open. The aim is to prevent any opportunity for intimate contact. Unless absolutely required, patients should not be asked to disrobe.

It's also important for you to be alert for any signs of transference and for flirtatious patients. If a patient says or does anything that even vaguely hints at impropriety, you should immediately make it clear that such behavior is not acceptable. This can be as simple as a stern look to a simple, "I'm sorry, but that kind of talk makes me uncomfortable." Or, it can be a more complete discussion of the proper boundaries to a patient-doctor relationship, with a CA present.

Never merely shrug it off or ignore it and definitely never respond in kind, even if you think both of you are only having "harmless fun." Be sure to document the incident in the patient's files, explaining exactly what the patient did or said and your own response.

In an ABC News interview, Dr. Thomas Gutheil, professor of psychiatry at Harvard Medical School, explained that, "Many harmless phenomena (of which misconduct is not one) become more serious with a failure to document what has occurred. Clinicians who fail to document misbehavior out of their own embarrassment are failing to respond appropriately to relevant clinical material, whose absence would imply concealment of wrongdoing."

In that same interview, attorney Elizabeth Kuniholm noted, "It is absolutely the doctor's duty to maintain proper boundaries with patients. It is, therefore, the doctor's duty to make sure those boundaries are not crossed, even if it is the patient who initiates it."

Depending on the specific situation, the doctor can do one of three things:

***  Continue seeing the patient as usual, being alert to any other statements or actions that indicate he or she intends to continue making inappropriate advances.

***  Continue seeing the patient, but only with a C.A. or other assistant present in the room.

***  Terminate the relationship with the patient and make a referral to another chiropractor.

Include a full explanation of your decision on the patient's file.

Clearly, doctors of chiropractic face a particular challenge when it comes to sexual misconduct. They are in a "hands on" profession that relies on physical touch. Part of chiropractic's popularity is directly related to its level of compassion and empathy. Here is a profession that often considers patients "practice members" -- almost part of an extended family. Yet, today that attitude has to be carefully balanced with an awareness of the growing number of lawsuits filed for sexual misconduct.

In a world where even a wink and a smile can be mis-interpreted, it's important to eliminate as many risks as possible.

One other very important step to take is to make sure your malpractice insurance policy covers defense against sexual misconduct accusations. Shockingly, many policies do not provide such coverage, leaving doctors responsible for the huge costs of defending themselves in court or before their boards if any accusations of sexual misconduct are filed against them. For the record, the malpractice policy offered through CBS does have this vital coverage.

(As president of Chiropractic Benefit Services, Timothy J. Feuling assists doctors in maximizing their practices through the proper choice of insurance and related services. Mr. Feuling is available for speaking engagements at state conventions and other chiropractic events. Doctors may contact him with questions, comments, and requests for insurance quotes at 4479 Philbrook Square, San Diego, CA; by phone at 800‑883‑0412; or by e‑mail: feuling@cbsmalpractice.com . Or visit www.cbsmalpractice.com  for more information.).